A Multi-Phase Quality Initiative to Improve Processes of Care for Non-small Cell Lung Cancer (NSCLC) in US Community Cancer Centers

Introduction: Accurate staging, biomarker identification, and high-fidelity processes of care are critical for evidence-based treatment of NSCLC. To this end, the Association of Community Cancer Centers (ACCC) conducted a national, multi-phase effort to identify and provide guidance on key issues related to optimal care for patients with stage III/IV NSCLC. Methods: The quality improvement (QI) initiative, guided by an expert steering committee, included 5 phases: 1: Site Selection;2: Topic Identification, Quality Measure Development & Education;3: Data Collection & Analysis;4: Implementation of Educational Intervention;5: Analyze & Repeat. After site selection, baseline data were collected to assess key areas (demographics and clinical features, biomarker testing, process of care) across all sites using standardized data collection instruments. Baseline data were reviewed with each project team and a QI topic was selected via planning tele-conferences. An onsite (or virtual) full-day workshop was conducted with multidisciplinary cancer team members, including invited expert faculty, to define goals and develop site-specific QI projects. The main objects were to implement process-level improvements and develop quantitative benchmarks. Follow-up data collection (quantitative, qualitative, and process-level) was specific to each project and site (some were modified due to COVID-19) and all sites provided follow-up data on biomarker testing. Statistical analyses included summary statistics, frequency tables, and chi-square tests. Results: In pre-implementation (baseline) data collected at the six sites from 2018-2019, median patient ages were 65-72 years;50% Stage III and 50% Stage IV. The race distribution of patients and proportions insured under Medicare, Medicaid, or commercial varied substantially across sites. Biomarker testing also varied in 2018-2019, with clinicians having requested testing for 48-94% of Stage IV patients (with four sites >80%). When biomarkers were evaluated, EGFR and ALK were included in 70-100% of tests, BRAF and ROS1 in 14-87% of tests, and NTRK testing was rare. PDL1 was evaluated in 40-97% of patients. Important process-level improvements were achieved with the QI projects in 2020. Two sites focused on immune-related adverse events (irAEs), conducting a clinician survey to assess gaps in knowledge and care around identification and management of irAEs and developing a patient questionnaire to identify early signs of irAEs. A site focused on clinical trial enrollment and education and established a referral partnership with an NCI-designed cancer center. Two sites focused on biomarker testing, making progress towards standardization. Interventions included creation of a process map for ordering, optimizing workflow by standardizing key elements and template order-sets, increasing liquid biopsy use, and implementing pathology-driven reflex testing at diagnosis. Three sites improved testing rates of Stage IV patients from baseline to follow-up (48% to 81%;67% to 100%;80% to 100%). When biomarkers were tested in 2020, the use of panel testing was 87% overall (>70% for every site). Liquid biopsy was used regularly at three sites, testing 23%, 25%, and 40% of patients. Conclusion: This initiative aided six cancer programs in improving processes of care for patients with stage III/IV NSCLC. Despite some COVID-19 disruption, participating sites remained committed to implementing changes around biomarker testing, well-coordinated care delivery, and symptom management. Keywords: biomarker testing, immune-related adverse events, Quality of Care